Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

Objectives: To develop and assess Pediatric AppropriatenessEvaluation Protocol for India (PAEP-India) for inter-rater reliabilityand appropriateness of hospitalization.Design: Cross-sectional study.Setting: The available PAEP tools were reviewed and adaptedfor Indian context by ten experienced pediatricians followingsemi-Delphi process. Two PAEP-India tools; newborn (?28 days)and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness ofadmission and inter-rater reliability between assessors.Participants: Two sets of case records were used: (i) 274cases from five medical colleges in Delhi-NCR [?28 days (n=51);>28 days to 18 years (n=223)]; (ii) 622 infants who werehospitalized in 146 health facilities and were part of a cohort (n=30688) from two southern Indian states.Interventions: Each case-record was evaluated by twopediatricians in a blinded manner using the appropriate PAEP-India tools, and ‘admission criteria’ were categorized asappropriate, inappropriate or indeterminate.Main outcome measures: The proportion of appropriatehospitalizations and inter-rater reliability between assessors(using kappa statistic) were estimated for the cases.Results: 97.8% hospitalized cases from medical colleges werelabelled as appropriate by both reviewers with inter-rateragreement of 98.9% (k=0.66). In the southerm Indian set ofinfants, both reviewers labelled 80.5% admissions as appropriatewith inter-rater agreement of 96.1% (k= 0.89).Conclusions: PAEP-India (newborn and child) tools are simple,objective and applicable in diverse settings and highly reliable.These tools can potentially be used for deciding admissionappropriateness and hospital stay and may be evaluated later forusefulness for cost reimbursements for insurance proposes.

Selenium supplementation for the preterm Indian neonate.

Deficient antioxidant defenses in preterm infants have been implicated in diseases such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, periventricular leukomalacia, and intraventricular hemorrhage. The antioxidant properties of selenium make it important in the nutrition of very low-birth weight (VLBW) infants. Selenium is a component of glutathione peroxidase (GPX), an enzyme that prevents the production of free radicals. Preterm infants have low selenium stores and require supplementation by parenteral and enteral routes. This communiquι reviews the beneficial role that selenium supplementation might play in improving neonatal outcomes.

Vitamin E Level in Normal Indian Children.

Objective/Background: The study was conducted a aim to determine vitamin E levels in normal Indian children. Vitamin E has positive effect on cardiovascular health through its ability to influence signaling process in platelets and also has significant role in neurodegenerative disorders. Vitamin C and vitamin E supplementation retards the progression of coronary arteriosclerosis during early stage following cardiac transplantation. It also mediates the generation and availability of superoxide and nitric oxide and is beneficial in preventing prostate cancer or delaying disease progression. Material and methods: Study included 30 healthy children of either sex, they were divided into three groups each of 10 children i.e., Group I (2-4 years) mean age 3.42 years, Group II (4-6 years) mean age 5.35 years and Group III (6-10 years) mean age 8 years. Vitamin E levels were measured in their serum fluorometric micro methods for serum tocopherol as described by Hansen and Warwick. Result: In Group I, the mean ± SEM value of vitamin E was 2.74 ± 1.10 μgm/ml, in Group II it was 2.82 ± 1.11 μgm/ml and in Group III it was 2.93 ± 1.12 μgm/ml. Conclusion: Serum vitamin E levels in healthy Indian children is 2.82 ± 1.11μg/ml and there is no sex predilection.

Congenital Facial Palsy with Bilateral Anotia.

Congenital facial palsy is generally considered developmental or acquired. Most of the cases are related to birth trauma. Herein we report a case of congenital facial palsy with bilateral anotia and external auditory canal atresia.

Profile of Erythroblastopenia in Childhood.

Bone marrows of hospitalized children with anaemia were examined to study the incidence and profile of erythroblastopenia in childhood. Forty children aged between 7 months to 12 years with anaemia, reticulocytopenia and isolated erythroblastopenia on Bone marrow aspiration were evaluated during 2 years duration. Depending on duration of illness and their recovery the disease was categorized into acute, subacute and chronic erythroblastopenia. The disease was found to be associated with PEM and nutritional anaemia (55%), gastroenteritis (12.5%) and respiratory tract infections (12.5%) amongst others.

Effect of High-dose Phenobarbital on Oxidative Stress in Perinatal Asphyxia: An Open Label Randomized Controlled Trial.

Objective: To evaluate the effect of high dose phenobarbital on lipid peroxidation and antioxidant enzymes in perinatal asphyxia. Design: Open label, Randomized controlled trial. Setting: Neonatal intensive care unit of a tertiary care teaching hospital. Participants: 72 full term inborn neonates with severe birth asphyxia. Methods: Neonates were randomized to Study (phenobarbital) group and Control group. The infants in the study group received phenobarbital infusion (40mg/kg) within first two hours of life while babies in the control group did not receive any phenobarbital. Rest of the management in both the groups was as per the unit protocol for the management of hypoxic ischemic encephalopathy. A cerebrospinal fluid examination was done at 12 ± 2 hours of life to determine the levels of superoxide dismutase, glutathione peroxidise and malonyldialdehyde. 60 neonates were followed up at 1 month of age when a detailed neurological examination was done. Results: Four neonates in the study group and six neonates in the control group died during the study. Two neonates in the study group were lost to follow up. The cerebrospinal fluid lipid peroxides and antioxidant enzymes were significantly lower in the phenobarbital group as compared to the control group. The neurological outcome at one month follow up was found to be comparable between the two groups. Conclusion: Phenobarbital (40mg/kg) given in the first two hours of life in term neonates with perinatal asphyxia led to a decrease in CSF levels of lipid peroxides and antioxidant enzymes at 12 ± 2 hours of life.

Safety and efficacy of Vinyl bags in prevention of hypothermia of preterm neonates at birth.

The present study was planned to evaluate the safety and efficacy of vinyl bags in prevention of hypothermia during resuscitation at birth in very low birth weight neonates. Sixty neonates of gestational age ≤32 weeks and birth weight ≤ 1500gm were randomised to either study group, or control group. Study group neonates were put in vinyl bags up to neck and the head was covered with a cap after drying immediately following delivery and resuscitated under radiant warmer. Control group neonates were resuscitated by conventional drying under radiant warmer. Mean axillary and rectal temperature recorded immediately after admission to NICU were significantly higher in the study group compared to control group. Temperature recorded after 1 hour of admission to NICU were however comparable between the two groups. As temperature maintenance in these VLBW neonates is of tremendous importance, it would make sense to recommend the use of vinyl bags during their resuscitation.

Semilobar holoprosencephaly in Seckel syndrome.

Seckel syndrome is a rare genetic disorder with autosomal recessive inheritance. It is associated with many CNS anomalies along with involvement of other systems. We present a case of Seckel syndrome with semilobar holoprosencephaly as associated CNS anomaly, which to the best of our knowledge has not been reported earlier.

KMC facilitates mother baby attachment in low birth weight infants.

OBJECTIVE: To determine whether Kangaroo mother care (KMC) facilitates mother baby attachment in low birth weight infants. METHODS: Over 16 month period 110 neonates were randomized into kangaroo mother care group and control group using a random number table. The kangaroo group was subjected to Kangaroo mother care for at least 6 hours per day. The babies also received kangaroo care after shifting out from NICU and at home. The control group received standard care (incubator or open care system). After 3 months followup, structured maternal interview was conducted to assess attachment between mothers and their babies. RESULTS: Mean birth weight was 1.69 +/- 0.11 Kg in KMC group compared to 1.690 +/- 0.12 Kg in control group (p>0.05). Mean gestational age was 35.48 +/- 1.20 week in KMC group and 35.04+/-1.09 week in the control group (p>0.05). KMC was initiated at a mean age of 1.72+/-0.45 days. The duration of KMC in first month was 10.21+/-1.50 hour, in the 2nd month was 10.03+/-1.57 hour and in the 3rd month was 8.97+/-1.37 hours. The duration of hospital stay was significantly shorter in the KMC group (3.56+/-0.57 days) compared to control group (6.80+/-1.30 days). The total attachment score (24.46+/-1.64) in the KMC group was significantly higher than that obtained in control group (18.22+/-1.79, p< 0.001). In KMC group, mother was more often the main caretaker of the baby. Mothers were significantly more involved in care taking activities like bathing, diapering, sleeping with their babies and spent more time beyond usual care taking. They went out without their babies less often and only for unavoidable reasons. They derived greater pleasure from their babies. CONCLUSION: KMC facilitates mother baby attachment in low birth weight infants.

Fortified human milk in the small for gestational age neonate.

OBJECTIVE: To assess the nutritional advantage of fortified human milk in the small for gestational age neonate. METHODS: Term asymmetric small for gestational age babies were randomly assigned to either the study group or the control group. The babies in the study group received fortified EBM, (more proteins, calories, vitamins and minerals) whereas babies in the control group received EBM only. Babies were followed up weekly for a period of 28 +/- 2 days for physical growth (weight, length and OFC). Biochemical markers of nutritional status (Blood urea, serum calcium, phosphorus, alkaline phosphatase, serum electrolytes and serum protein) were done initially and then on Day 28 +/- 2. RESULTS: The weight gain in the study group (38.77 +/- 7.43 g/day) was significantly better than in the control group (28.71 +/- 3.18 g/day). The length and OFC gain in the study group (1.14 +/- 0.33 cm/week and 0.62 +/- 0.07 cms/week, respectively) were significantly better than in the control group (0.87 +/- 0.17 cm/week and 0.49 +/- 0.07 cm/week respectively). The biochemical markers of nutrition, however, were not significantly different in the two groups. CONCLUSION: Fortified breast milk results in improved physical growth in the term asymmetric small for gestational age neonate.

Magnesium therapy in birth asphyxia.

OBJECTIVE: Glutamate plays a critical role in the hypoxic ischaemic neuronal death. Two mechanisms of glutamate- induced neuronal death have been identified. One is rapid cell death that occurs in minutes and the second is delayed cell death that occurs over hours and is initiated principally by the activation of the N-methyl D-Aspactate (NMDA) receptor. Magnesium (Mg) is an NMDA receptor blocker. Systemic administration of Mg after a simulated hypoxic ischaemic insult has been shown to limit neuronal injury in several animal models. However, before embarking on to the use of Mg for neuronal protection in the human neonate it is important to study the safety and side effects of Mg administration. METHODS: Forty terms, appropriate for gestational age babies with severe birth asphyxia (1 min Apgar score < 3 and 5 min Apgar score < 6), were randomly assigned to either the study group or the control group. Infants in both groups were treated as per unit protocol except that babies in the study group received intravenous injection of magnesium sulphate 250 mg/kg within half an hour of birth and subsequently 125 mg/kg at 24 and 48 hours of life. RESULTS: The mean cord blood serum Mg levels were 0.78 (+/- 0.047) mmol/L in the control group and 0.779(+/-0.045) mmol/L in the study group. The serum Mg levels at 3, 6, 12, 24, 48 and 72 hours of life were 1.87(+/-0.6), 1.65(+/-0.059), 1.468 (+/-0.91), 1.881 (+/- 0.053), 1.916 (+/- 0.053) and 1.493 (+/- 0.084) mmol/L respectively in the study group. All these values were significantly higher than those obtained in the control group (p< 0.001). No significant alterations in heart rate, respiratory rate, oxygen saturation and mean arterial pressure were seen, following magnesium infusion with either 250 mg/kg or 125 mg/kg dose. The serum Mg levels in the study group ranged between 1.493 (+/- 0.084) and 1.916(+/-0.053) mmol/L, which are considered to be in the neuroprotective range. CONCLUSION: Injection MgSO4 administered in a dose of 250 mg/kg and 125 mg/kg as an intravenous infusion is safe and the Mg levels obtained are in the range considered to be neuroprotective.

Aztreonam.

Aztreonam belongs to the monobactam group of naturally occurring antibiotic compounds characterized by a monocycling ring structure. Aztreonam is the first monobactam that has been approved for use in pediatric medicine by US FDA in the year 1998.

Neonatal adrenal hemorrhage with intraperitoneal spill managed conservatively.

A neonate presented with anemia, hyperbilirubinemia and bilateral flank fullness at 23 days of age. Ultrasound abdomen showed bilateral adrenal hemorrhage with intraperitoneal extension on the left side. This was managed nonoperatively and the hematoma resolved completely. Literature regarding this rare entity is described.

Multicystic encephalomalacia.

Antepartum death of a fetus in a multiple gestation can be associated with mortality or major morbidity in the survivor. This article reports a rare case of multicystic encephalomalacia that occurred in the survivor twin with antepartum death of its co-twin. Its pathology and pathogenesis are discussed with review of literature.

Agenesis of the right lobe of liver.

Congenital anomalies involving the lobes of the liver are rare. Hypoplasia and agenesis occur more often in the left lobe. Agenesis of the right lobe is a rare anomaly with only about 42 cases reported in literature. In this communique we report one such case of agenesis of the right lobe of liver. A brief review of literature is made and its diagnosis and differential diagnosis are discussed.